Emerging Tobacco Products: “New Products, Same Targets” North Carolina Health and Wellness Trust Fund Annual Meeting Oc

1. Emerging Tobacco Products: “New Products, Same Targets” North Carolina Health and Wellness Trust Fund Annual Meeting October 22, 2009 Amber Thornton-Bullock, MPH, CHES

2. Legacy Overview The American Legacy Foundation (Legacy) was created as the result of the MSA 46 States and 5 US Territories are included in the MSA Celebrating 10 years Mission is to build a world where young people reject tobacco and anyone can quit In addition to public education campaigns, truth® and EX® Legacy seeks to partner with communities most impacted by the toll of tobacco Restrictions of MSA – no lobbying, vilification

3. Emerging Products Little Cigars and Cigarillos Snus and Snuff Dissolvables Hookah New Cigarettes E-Cigarettes

4. The Product: Little Cigars and Cigarillos

5. Cigars are defined by the US government as “any roll of tobacco wrapped in leaf tobacco or in any substance containing tobacco”.1 Size Comparison: Cigarette < 3 lbs per 1000 Little Cigar < 3 lbs per 1000 Cigar > 3 lbs per 1000 (includes cigarillo) Little Cigars and Cigarillos 1. USC 5702. Available at: http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=browse_usc&docid=Cite:+26USC5702

6. Cigarillos

7. Cigarillos… …Often look like smaller versions of traditional stogie cigars. …come in a variety of flavors (cherry, apple, menthol, wine, etc.).

8. Cigarillos Sales of cigarillos increased by almost 150% between 1997 and 2007.¹ Phillip Morris now owns Black & Mild, the most popular brands of cigarillos. 1Maxwell JC. The Maxwell Report: Cigar Industry in 2007. Richmond, VA: John C. Maxwell, Jr. 2008

9. Where do Cigarillos fit? Cigars are divided into two federal tax categories based on weight: 1) small cigars 2) large cigars Cigarillos have no current federal tax definition Cigarillos are included in “large cigar” category despite significant differences in their marketing and packaging from that of typical large cigars

10. Small/Little Cigars

11. Little cigars… …available in a variety of flavors (vanilla, grape, watermelon, cherry, chocolate, menthol, etc). …include flavors that may appeal to youth and young people. Carpenter CM, et al. New Cigarette Brands with Flavors that Appeal to Youth: Tobacco Marketing Strategies. Health Affairs, 2005; 24(6): 1601-1610.

12. Cigar or Cigarette in Disguise???

13. Little Cigars Sales of little cigars have increased by 240% between 1997-2007¹. A review of formerly-secret tobacco industry documents finds that little cigars were intended to replace cigarettes as advertising became restricted². Increase in consumption is frequently attributed to increases in tax on cigarettes, as cigars have historically been taxed at dramatically lower rates. 1Maxwell JC. The Maxwell Report: Cigar Industry in 2007. Richmond, VA: John C. Maxwell, Jr. 2008. 2Delnevo CD, Hrywna M. “A whole ‘nother smoke’ or a cigarette in disguise: how RJ Reynolds reframed the image of little cigars. American Journal of Public Health, 2007; 97(8):1368-75.

14. Cigar Tax Rate New Federal tax rates as of April 1, 2009: Small cigars: $1.01 per pack of 20 (old rate was $.04/pack) Large cigars: 52.75% of manufacturer’s price capped at $.40 per cigar (old rate was 20.72% of manufacturer’s price capped at $.05 per cigar) Source: 26 USC 5701 – as amended by the Children’s Health Insurance Program Reauthorization Act (P.L. NO. 111-003)

15. Little Cigar and Cigarillo Research

16. Challenges to Data No national surveys provide data stratified by the three main cigar products (small cigar, cigarillo and large cigar). Instead, cigar sizes are grouped which results in aggregated prevalence estimates that are not specific to any one product. These various products have unique characteristics; anecdotal evidence suggests they are smoked differently. Some tobacco users do not self report as cigar users until brands are specified.

17. Highlights from Extant Research 2000 Rigotti et al.: US College Students Use of Tobacco Products was assessed as part of the ongoing Harvard college Alcohol Survey Over 14000 randomly selected students, Cigar prevalence: 23% used in past year, 8.5% were current users 2005 Delnevo et al.: Lower cost of cigar products may be influencing youth consumption patterns of tobacco 2008 Soldz et al.: Cigar smoking and brand preference in a sample (n = 5006) of middle and high school students in Massachusetts 16% smoked cigars Phillies were most popular, followed by Black and Mild and Swisher Sweets 2008 Jolly: Little cigar use at a HBU focus groups of college students demonstrated that some believe these products to be less harmful than cigarette 2009 Terchek et al.: Current national survey items might not adequately measure cigar use, need for brand-specific items

18. National Study on Descriptive Epidemiology of Cigar Use Methods: Data Source:National Survey on Drug Use or Health (NSDUH) conducted by US Substance Abuse and Mental Health Services Administration (SAMHSA) Study Design: Annual U.S. annual household cross-sectional surveys; probability sampling Study period: 2002-2007 (6 cross-sectional surveys) Sample population: over60,000 people aged 12+ annually; nationally representative. Measures/Outcomes: prevalence of cigar “Ever use”, “Past 30-day use”, and frequency of use in past 30-days; demographics; risk behavior Mode of Questionnaire administration: audio computer-assisted self-interview (CATI) Statistical analysis: Weighted, stratified estimates of prevalence over time

19. Prevalence in Past 30-Day Cigar Use among for 18-25 year olds NSDUH 2002-2007

20. Prevalence in Cigar Ever Use and Past 30-Day Use by Age NSDUH 2002-2007

21. Cigar Brand Preferences NSDUH 2002-2007

22. Black & Mild brand use by Race NSDUH 2002-2007

23. Summary of Data on Little Cigars and Cigarillos Results: • Prevalence and brand preference variation exists by age, gender and race/ethnicity. • Prevalence rates are highest in male adults 18-25 years. • The brands most popular to those aged 18-25 are ones that represent little cigars and cigarillo products. NSDUH Data Limitations & Potential Solution: • Only people who say they smoke cigars, cigarillos, or small cigars were asked the brand question. But some youth recognize the brand names, only. Surveys should ask about specific brands to improve accuracy in self-reported use of these products. • Brand names and/or photographs could be included in the initial screener question on survey instruments to achieve this.

24. Marketing Strategies How the industry keeps hooking new customers

25. Marketing of Little Cigars and Cigarillos Magazine Ad in Sports Illustrated , 2001 Magazine Ad in Car and Driver, 2007

26. Coupons

27. Swisher International

28. Advertisement: WebsiteRoyal Blunts

29. Advertisement: WebsiteCaptain Black

30. Advertisement: Promotions Winchester An American Sweepstakes Royal Blunts Discounts available through retailers Hunid Racks They sell CD singles/DVD’s featuring their artists B-Legit, Richie Rich, YUKMOUTH and Messy Marv Link to get a “Hunid Racks Debit Card”

31. Cigarillos on Facebook & YouTube Some users decided to make Facebook groups and YouTube videos for their favorite brands. Problem: Facebook users are traditionally of a younger age bracket.

32. Brand Promotion Case in point… shows the creative lengths the industry will go through to promote a brand. Phillies Adidas product line – limited release, no future plans for full release of product line

33. Brand Promotion • ARI Menthol 10’s Shoes • Made to look like Nike • Limited release in 2006

34. In-Store Placement: Eye Level is Buy Level

35. In-Store Placement: Eye Level is Buy Level

37. Emerging Tobacco Products

38. Snus and Snuff Snus. A spitless tobacco packaged in small teabag-like pouches. Modeled after a Swedish product Marlboro snus – tested starting 2007 in plastic packs, now in smaller foil packs Camel snus –  Ads now appear nationally in magazines Moist Snuff.  Finely ground tobacco packaged in cans or pouches, sold moist (placed between the lower lip or cheek and gum)  Marlboro moist snuff: tested starting in 2006, discontinued 2009  Camel Dip: testing starting June 2009 While overall prevalence of smokeless tobacco use has declined in recent years, prevalence of moist snuff use is on the rise in men aged 18-44 and daily cigarette smokers. (Simard et al., APHA 135th meeting, 2007) While cigarette smoking sales continue to decline in the US, moist snuff continues to grow in popularity, accounting for 71% of the US smokeless market in 2006. (Carpenter et al., Tobacco Control, 2009;18:54-59) Images: Philip Morris, tobaccoproducts.org. socialbranding.org

39. Dissolvable Tobacco • Three new dissolvable tobacco products made of finely milled tobacco, dissolve in the mouth; do not require spitting. Orbs began test marketing in Jan, 2009 • Orbs: mint-sized • Strips: appear like Listerine breath strips • Sticks: toothpick-like • Packaging appearance seems like it may appeal to youth Images: Reynolds, Harvard School of Public Health

40. Hookah • Water pipe smoking that hails from Middle East • Water does not “filter” all the toxic compounds and chemicals

41. Hookah Poses serious health risks to smokers and others exposed to smoke. A typical one-hour long Hookah session involves inhaling 100-200 times the volume of smoke inhaled in a single cigarette. CDC Factsheet

42. E-Cigarettes Images: DSE901 manual, Instead electronic cigarettes, Journal Star Battery-operated devices generally containing cartridges filled with nicotine, flavors and other chemicals. Vaporized, then inhaled. Available in flavors, such as chocolate or mint, which may appeal to young people. One small sample done by FDA found diethylene glycol (a chemical used in antifreeze, toxic to humans) Other samples FDA analyses detected carcinogens, including nitrosamines

43. New Cigarettes Newport M: available only in Pennsylvania Virginia Slims Superslims: introduced late 2008, early 2009, come in “purse packs”, thinner; public health groups have called them out for marketing toward women and younger girls, with fashionable colors, and sleek sparkling boxes. Camel Crush: introduced fall 2008, filter contains capsule to be crushed by squeezing, releasing menthol flavor Marlboro Blend No. 54: introduced summer 2009, Mentholated Images: tobaccoproducts.org, tobaccowatch.org

44. RYO Vending Machine

45. Examples: Actions Taken By Others Maine- in 2007 banned most flavors of cigars and cigarettes, law takes effect July 1, 2009. Baltimore City- banned single sales of cheap cigars, requiring that they be sold in packs of 5 to attempt to reduce youth usage.

46. Get Involved Hold public forums on this issue Research gaps: This can be addressed by adding product/brand specific questions on local surveys Educate youth advocates and community at large on the issue and that these products are harmful

47. Get Involved Ensure that materials, campaigns and resources for tobacco prevention and control are relevant, culturally competent and linguistically appropriate Tax increases ultimately have public health benefits – generally less product consumption

48. Questions? Contact Information: abullock@americanlegacy.org, 202-454-5591